Author Archives: Serife Tekin

About Serife Tekin

philosopher, nomad, monad

Tele-Psychiatry Ethics and the COVID-19 Pandemic

The COVID-19 Pandemic presents unique challenges for patients with mental disorders, their care givers, mental healthcare professionals, and bioethicists. Professor John Z. Sadler and Professor Şerife Tekin engage in a productive exchange pertaining to ethical issues in psychiatric care in the time of the COVID-19 pandemic.

In what follows you will read a psychiatric case shared by Professor Sadler based on his recent experience at his hospital and Professor Tekin’s reflections on the ethical issues involved in the case. It is important to note here that this exchange occurred on April 1, 2020, in Texas, US, in the midst of a lockdown. We believe that the historical moment counts for a lot in this case. We welcome our readers to join the conversation in the comments.

Case for AAPP Blog, April 1, 2020*
By John Z Sadler, MD, University of Texas at Southwestern

*Details have been changed to preserve anonymity of the family.

As are clinics across the USA, our clinic has converted all of our visits to virtual ones. Our clinic is part of a safety-net healthcare system, so our patient population is of limited means. For this reason, we offer currently only telephone-call based tele-psychiatry, without video.

Mr. B is a 62 year-old man with chronic undifferentiated schizophrenia who lives at home on disability, assisted by his 83 year-old mother, while aged, is in relatively good health. At our last tele-psychiatry audio visit with Mr. B, he showed evidence of clinical deterioration compared with his last visit in-person with us 6 weeks ago. On his consented-to tele-psychiatry visit, he described persecutory delusions involving the “X-people” who were “stalking us” (referring to mother). He expressed some intent to retaliate violently against the X-people but has not actually confronted them, or anyone, as both the patient and mother are complying with the community order to stay at home except for essential activities (e.g., health care, grocery, exercise outdoors). Moreover, Mr. B was quite stable on medications six weeks ago, but now the patient has discontinued medications for unclear reasons. The mother, Mrs. B, who spoke over the speakerphone connection, said that Mr. B was getting worse: more pacing, hearing more voices, ranting about the X-people, but Mrs. B did not feel threatened by the patient and said the patient had never been violent with anyone.

The clinic resident, Dr. S, and attending physician (me) were concerned nevertheless about the patient’s relatively-rapid deterioration, especially in the face of meeting him for the first time in the prior visit. Dr. S advised Mrs. B about how to take out a mental-illness warrant if she needed assistance. (A mental-illness warrant is a Texas court-ordered emergency-psychiatry involuntary evaluation not to exceed a 3 day period.) The patient was, perhaps surprisingly, unperturbed by this advice. After discussing quickly offline, Dr. S and I decided that the balance of risk and benefit did NOT favor us recommending, at this time, the mother take the patient to the emergency department, given both members of the family were at high-risk for serious complications from COVID-19 infection, and had no protective gear of their own. Instead, Dr. S would follow up with the family frequently over the phone, and continue to encourage Mr. B to resume his medications.

This case, for us, raises ethical questions about managing the unstable patient over tele-psychiatry when usual clinic resources are not available, and while increasing the level of personal-contact care poses its own serious risks from COVID-19. Moreover, we suspect that this problem, writ large over the community, poses community risks as unstable individuals with psychosis may increasingly not be able to adhere to safe-distancing and other public infection-control steps, while at the same time have limited mental health in-person support.

A commentary, April 1, 2020
By Şerife Tekin, PhD, University of Texas at San Antonio

Thank you, Professor Sadler for sharing this case with us. It is pertinent that we address and engage with ethical issues pertaining to individuals with mental disorders during this difficult time. There is a long list of problems that all members of the society are faced with during the COVID-19 pandemic, e.g., trying to avoid contexts in which one can get infected with the virus, continuing to work in jobs that contain high risk (healthcare workers, workers at the grocery stores, home delivery agents), increased unemployment, facing with financial insecurities, confronting food insecurity, etc. In addition to these, individuals with mental disorders are vulnerable to exacerbation of their symptoms under the pandemic, such as increased insomnia due to loss of daily routines, increased volatility in mood, and as in the case of Mr B, disruptions in medical treatment and increased persecutory delusions. Such problems further deteriorate or even pose threats to individuals around the patients, including their caregivers; in this case increased risk of violence against others.

I would like to focus on two themes that emerge in this case. The first is the evaluation of advantages and disadvantages of tele-medicine. A big problem in contemporary healthcare, and mental health care in particular, is the gap between the needs of individuals with mental disorders and the resources dedicated to care. For example, in 2016, 18.3% of all US adults were diagnosed with a mental disorder, and of these, only 43.1% received some kind of treatment, e.g., inpatient or outpatient counseling or prescription medication (Substance Abuse and Mental Health Services Administration 2017). Among other things, reasons for not receiving help include the lack of available services, inability to recognize symptoms, and the cost of treatment. Advances in computer technology, the applications artificial intelligence, and the use of data analytics in biomedicine are creating optimism, however, as many believe these technologies will fill the need-availability gap by increasing resources for mental health care. While tele-medicine, and in this context, tele-psychiatry offers tremendous resources, they are not without significant limitations. This case illustrates both.

On the one hand, in circumstances like those presented in the COVID-19 pandemic, tele-psychiatry enables treatment of patients with mental disorders without having to expose them and their caregivers to increased risks of getting sick, or community spread. As it is recently reported, there has been an increase in virtual psychotherapy during the COVID-19 pandemic, enabling individuals to receive the mental health counseling they need. Professor Sadler’s case, however, also calls into question of how fit mental disorders are for being treated remotely. While I do not want to overstate the differences between mental and physical disorders, the very nature of some mental disorders are so that what is recommended and effective in treating physical disorders may actually make the experience of mental disorders worse. Take social distancing. It is a good guide for preventing and treating patients with COVID-19. Using tele-medicine, patients can get advice on whether they should stay at home or see a healthcare practitioner. What usually comes out through this interaction over the phone is that even if the individual has the symptoms of the COVID-19, as long as they do not require intensive care, they could and should stay at home. However, staying home may make the symptoms of some mental disorders worse: Added isolation through social distancing, the loss of routines that help regulate mental health may all exacerbate the person’s condition. Or, as in the case of Mr. B, the patient may need more hands-on or emergent care at a health institution. While my observation does not solve the problem in the current situation it will perhaps caution tele-medicine and tele-psychiatry optimists to recognize the intrinsic limitations of these technologies in treating mental illness.

The second theme is how must healthcare professionals navigate the potential risks involved in different decision scenarios? In this case Dr. S is conflicted between the decision to remain to monitor the apparently deteriorating mental health of a patient through tele-psychiatry and the decision to recommend in-person care, due to scarcity of personal protective equipment available for patients, their caregivers, and the healthcare professionals. Mainstream bioethics often recommends a medley of ethical guidelines in such scenarios. Following the main principles of bioethics may be one option, i.e., avoidance from causing further harm to the patient (non-maleficence), aiming to improve the condition of the patient (beneficence), respecting patient’s autonomy, and a fair treatment of the patient in question. None of these principles are straightforwardly helpful here. Take the non-maleficence and beneficence principles: On the one hand, Mr. B might be worse off by staying at home due to increased risk of self-harm and harm to others; he may also be worse off by being hospitalized, due to increased risk of exposure to COVID-19. It is not obvious which of these decisions would make the patient worse or better off. The power of principle of autonomy as a guide is limited as well. In this case, arguably, the patient has limited agency and thus autonomy. His caregiver, who is in a position to make decisions regarding Mr. B’s care is also unsure about the right course of action to follow, as neither hospitalization nor continuing to be cared for at home through tele-psychiatry seem to offer straightforward solutions. So, the healthcare professional cannot just straightforwardly follow the caregiver’s wishes. The principle of justice, which encourages healthcare professionals to treat patients fairly, also does not offer any concrete solutions in the time of a pandemic when medical resources are scarce.

In these situations, it is wise to turn to virtue ethics or feminist ethics as potential guides; which is what I take Dr. S has followed. Unlike the principle-based guidelines of mainstream bioethics, both virtue ethics and feminist ethics take seriously the context of the medical case in question. Instead of chasing after the universals, they value the particulars. Virtue ethicists promote healthcare professionals to develop virtues and be guided by those virtues in caring for the patients. Some of these virtues include being compassionate, thoughtful, attentive to the patient’s identity and relationships in determining their needs, and being aware of and sensitive to social and cultural norms. In this case, in consultation with her colleague, Dr. S. seems to have acted virtuously, in so far as she was (i) compassionate, (ii) decided to seek collaborative decision-making, (iii) took the individual context of Mr. B seriously – as a person with increased risk of negative outcome if gets sick with COVID-19, with a caregiver who is also part of the similar risk group. After this process, she decided to increase the frequency of her follow ups with the family to continue to monitor the situation and continue to encourage Mr. B to resume his medications.

Feminist bioethicists are committed to understanding persons not as solitary agents living independent from each other but, rather, as intrinsically relational beings that exist and flourish through interconnected relationships. Dr. S’s attention to the relationship between the patient and his caregiver is illustrative of feminist commitments. For instance, she prepared for a possible worse-case scenario and advised Mrs. B, Mr. B’s caregiver, on how to get a mental-illness warrant if she needed assistance. She also took cues from patient’s “surprisingly, unperturbed” response to this advice and recommended that him to not be hospitalized at this time. Her attention to the relationship between her and Mr. B, as well as her seriousness about explicitly communicating with the patient’s caregiver exemplifies what feminist bioethicists strive for in making tough decisions.

AAPP 2016 Meeting Schedule, May 14-15, Atlanta

Date: May 14-15, 2016

Location: Atlanta Marriott Marquis Hotel, M303-304
265 Peachtree Center Avenue
Atlanta, GA 30303

Program Chairs: Serife Tekin, Ph.D., Assistant Professor of Philosophy, Daemen College; Amherst, NY stekin@daemen.edu; Peter Zachar, Ph.D., Professor of Psychology , Associate Dean, College of Arts and Sciences, Auburn University Montgomery, Montgomery, AL pzachar@aum.edu

THERE IS NO FEE FOR ATTENDANCE/NO REGISTRATION REQUIRED

Saturday, May 14, 2016

8:30 Welcome to AAPP 2016
Claire Pouncey – President

Session 1: Moderator Ginger Hoffman

8: 40 RDoC: Out of the fire and into the frying pan?
Robyn Bluhm
9:00 Discussion

9:10 Handwaving at validity – Can we measure psychological constructs?
Claire Pouncey
9:30 Discussion

9:40 RDoC and the problem of normativity: conceptual analysis vs. philosophy of biology
Reiner Schuur
10:00 Discussion

10:00 BREAK

Session 2: Moderator Christian Perring

10: 15 Announcement of Jaspers Award Winners
Christian Perring

10:25 Letting many flowers bloom: the importance of methodological pluralism in the study of mental illness
Brent Kious
10:45 Discussion

EDWIN R. WALLACE IV LECTURE
Moderator – Peter Zachar

11:00 Neurocentrism: implications for conceptualizations of mental disorder
SCOTT LILIENFELD
11:40 Discussion

12:00 LUNCH

Session 3: Moderator Aaron Kostko

1:30 Extended mental disorder: worries for reductionism
Rachel Cooper
1:50 Discussion

2:00 Psychopathy and science
Emma Satloff-Bedrick & Jeff Bedrick
2:20 Discussion

2:30 BREAK

2:45 On the ethics of description in psychiatric nosology from DSM to RDoC
Kathryn Tabb
3:05 Discussion

3:15 The normal, the pathological, and RDoC: what about race and gender?
Doug Porter
3:35 Discussion

3:45 BREAK

Session 4: Moderator Jessica Wahman

4:00 Attachment within the RDoC: promising ‘biomarkers’ carrying deceptively complex conceptual baggage
Kevin Keith
4:20 Discussion

4:30 Keep calm and embrace futility
Alexander Parker
4:50 Discussion

Sunday May 15, 2016

Session 5: Moderator J. J. Rasimus

9:00 The explanatory importance of levels and mechanisms
Kelso Cratsley

9:20 Discussion

9:30 Should psychiatric nosology be constrained by underlying causal mechanisms?
Nicolaus Slouthouber
9:50 Discussion

10:00 Missing the middle: psychosis and temporal lobe epilepsy
Valerie Hardcastle
10:20 Discussion

10:30 BREAK

Session 6: Moderator Michael B. First

10:45 RDoC’s special kind of reductionism and its possible impact on clinical psychiatry
Simon Goyer and Luc Faucher
11:05 Discussion

11:05 Hempel’s account of psychiatric taxonomy: its historical and contemporary interest
Jon Tsou
11:25 Discussion

11:45 LUNCH

KEYNOTE LECTURE
Moderator – Serife Tekin
1:15 Facts and Myths about RDoC
Uma Vaidyanathan
1:55 Discussion

2:15 BREAK

Session 7: Moderator Robyn Bluhm

2:30 Scientism and the enlightenment split
Nikola Andonovski
2:50 Discussion

3:00 Outcome measures in schizophrenia research
Phoebe Friesen
3:20 Discussion

3:30 BREAK

Session 8 Moderator Jeff Bedrick

3:40 What is a diagnostic error in psychiatry?
Dany Lamothe and Mona Gupta
4:00 Discussion

4:10 What does it mean to have a meaning problem? meaning, control, and the mechanisms of change in psychotherapy Garsen Leder
4:30 Discussion

4:40 Closing Remarks
Serife Tekin

 

Call for Papers: Bloomsbury Companion to Philosophy of Psychiatry

Call for papers: Bloomsbury Companion to Philosophy of Psychiatry

Psychiatry raises a number of important philosophical questions, spanning ethics, epistemology, and metaphysics. Moreover, philosophical attention to these issues has the potential to influence clinical practice and health policy, which in turn affects public understanding of mental disorders and the lives of patients.

This book aims to be an accessible introduction to philosophy of psychiatry for undergraduate philosophy majors, medical students, and residents in psychiatry, but also to be of interest to professionals new to philosophy of psychiatry. The contributions to the volume should draw explicit connections between themes in philosophy of psychiatry and the traditional areas in philosophy, particularly philosophy of mind, philosophy of science, ethics, social and political philosophy, and metaphysics. Sections on each of these broad areas will consist of several chapters that offer distinct, but complementary, approaches to the topic.

More specifically, we are especially interested in work that examines emotions/affectivity, narrative and first-person experiences, politics and patient perspectives (including the recovery movement), agency/autonomy, hermeneutic approaches to understanding mental disorders, issues in neuroethics, explanation in psychiatry, though we will also consider proposals on other topics.

Each chapter will be around 6000 – 7000 words, including bibliography, and the deadline for chapter drafts will be December 31, 2016.

An abstract of approximately 250 words to both Robyn Bluhm, rbluhm@msu.edu and Şerife Tekin, stekin@daemen.edu by March 18, 2016. You are also welcome to contact the editors with any questions.

Philosophy of Psychiatry at ISHPSSB 2015

Guest post by Natalia Washington:

Friends,

I just wanted to inform you about a very successful philosophy of psychiatry session, “New Dimensions in Philosophy of Psychiatry,” at the recent International Society for the History Philosophy and Social Science of Biology (ISHPSSB) conference in Montreal! (here is the conference webste: http://ishpssb2015.uqam.ca/)

Below, I share with you Kathryn Tabb, Phoebe Friesen, and I’s new work during our session. Before I do so, I want to highlight that there has been quite a few interesting philosophy of psychiatry presentations at the ISHPSSB, including Steeves Demazeux’s “The Ideal of Scientific Progress and the DSM”, and Serife Tekin’s “Self in Scientific Psychiatry.” I was delighted to see that we are a growing presence in the ISHPSSB community!

Here are the abstracts for our session:

New Dimensions in Philosophy of Psychiatry

In this session we examine some contemporary debates emerging in the philosophy of psychiatry, at the intersection of ethics, metaphysics, and philosophy of science, as philosophers, researchers, and practitioners begin to come to grips with psychiatry’s dual nature as a science and an evaluative system. In particular we ask, what is the appropriate ontological framework and methodology for psychiatric research? What kinds of things can psychiatry study and intervene upon? And, what kind of normative standards are the right ones to use in determining what counts as mental illness?

“Philosophy of Psychiatry after Diagnostic Kinds” Kathryn Tabb, HPS, University of Pittsburgh

A significant portion of the scholarship in analytic philosophy of psychiatry has been devoted to the problem of whether or not psychiatric disorders are natural kinds, and if they are not, what kind of thing they are. My contention is that this problem is fast growing less relevant to the concerns of practitioners and service-users of psychiatric medicine. Dissatisfaction with what I call the “diagnostic kind model” of psychiatric objects is currently appearing on a variety of fronts. Among clinicians of diverse orientations, it manifests as a dislike of, and in some cases open rebellion against, the hegemonic authority of the American Psychiatric Association (APA)’s Diagnostic and Statistical Manual of Mental Disorders (DSM). Among clinically-oriented researchers, it presents as a frustration with the demarcation of nosological boundaries that has so long occupied psychiatry as a science. Among scientifically oriented researchers, it is most obvious in the introduction by the National Institute of Mental Health (NIMH) of an alternative tool for classifying psychiatric research, the Research Domain Criteria project. I argue that by focusing on the problem of kindhood, philosophers have neglected the development of a conceptual account that could explain the sort of scientific progress that the NIMH is envisioning, which could also accommodate the sorts of challenges raised by practitioners about the insufficiency of the DSM to describe their patients or promote their best care. I take as my examples the employment of Richard Boyd’s homeostatic property cluster (HPC) kind account by various philosophers, and the “exemplar” account promoted by Dominic Murphy. I demonstrate that these accounts still rely on what I call the “received authority” of diagnostic kinds, the very assumption that the NIMH and others are criticizing.

“Let a Thousand Ontologies Bloom” Phoebe Friesen, Philosophy, CUNY

This project seeks to examine the way in which an overriding focus on the medical model in psychiatric investigations today stands in the way of the dual goals of psychiatric research, to heal and to explain. Like any model of the mind, the medical model contains assumptions regarding ontological priority, by attributing a certain kind of causal reality to a particular level (neurological), at the expense of others (cultural, psychological, genetic). During scientific investigation, attributions of ontological priority constrain what hypotheses will be tested, what is seen as relevant data, how that data is interpreted, and eventually what explanations and treatments will be developed. This suggests that today’s emphasis on the medical model may be leading us to miss out on potential explanations and treatments that could be developed in response to mental disorders. While an abundance of important work is being done focusing on the role of the brain in psychiatric illnesses and developing pharmacological treatments as a result, there are a number of levels or perspectives that are given far less attention, particularly those regarding an individual’s cultural and phenomenological experiences. For this reason, I argue that psychiatry would do well to adopt a stance of ontological pluralism, which encourages an exploratory and open-ended approach to ontology within research. Such an approach aims to lessen the impact of restrictive ontological frameworks on our potential for discovering relevant explanations and effective treatments that might not otherwise come into view.

“Individualism as a Solution to Paternalism in Psychiatric Practice” Natalia Washington, Philosophy, Purdue

While ideally a science consilient with the other sciences of the mind/brain, psychiatry also involves normative and evaluative concepts, as one goal of psychiatric practice is to alleviate the suffering caused by mental illness. But what kinds of evaluative standards are the right ones to use in determining what counts as mental illness? Because diagnosing an individual as having a mental disorder can be a way of saying that they have a condition that is bad and ought to be corrected, or that their pattern of behavior is somehow deviant or harmful, the evaluative nature of psychiatric diagnosis has historically been used as a tool of social control (Banaji, 2013; Satcher, 2001).

In this paper I argue that, in order to ensure that the concept of mental health will be a useful one for theorizing about human flourishing, it should pick out a real psychological phenomenon in human lives, which has significance to the individuals the theory is about. In short it must have normative authority, “the feature in virtue of which people have a reason to follow the imperatives of a normative theory” (Tiberius & Plakias, 2010). To this end, everyone to whom the theory is supposed to apply should have some motivation to care about what psychiatry recommends, and there should be standards of justification for these recommendations. I examine one contemporary attempt to articulate a normative theory for psychiatry—George Graham’s (2010) Rationality-in-Intentionality (RIT) thesis—and argue that it lacks normative authority. The specific norms RIT proposes come apart from what may actually be better for the individual in this case. Finally I argue that in order to solve the problem of paternalism, psychiatry must ground what it means to be mentally ill or mentally healthy in the concerns of individuals.

Looking forward to seeing you all again soon!

Natalia Washington

McDonnell Postdoctoral Scholar at Washington University, Saint Louis

www.nataliawashington.com

Call for Abstracts, AAPP 28th Annual Meeting, May 14-15, 2016 Atlanta, GA

Association for the Advancement of Philosophy and Psychiatry

28th ANNUAL MEETING May 14-15, 2016 Atlanta, GA

PHILOSOPHICAL ISSUES IN SCIENTIFIC PSYCHIATRY:
RDOC, DSM, MECHANISMS, AND MORE

Conference co-chairs: Şerife Tekin & Peter Zachar

Keynote speakers:

Scott O. Lilienfeld, Ph.D. Emory University

Uma Vaidyanathan, Ph.D. National Institute of Mental Health, RDoC Unit

The science of psychiatry advances by means of empirical research. Scientific cultures, however, rely upon on non-empirical commitments such as methodological preferences, criteria for good constructs, and decisions about how to allocate limited resources to a superfluity of scientific goals. For instance shortly before the publication of the DSM-5 ̧the National Institute of Mental Health announced the goal of ultimately replacing the DSM as a guide for scientific research in psychiatry. Their preferred alternative is called the Research Domain Criteria (RDoC), a classification matrix of basic psychological capacities that lend themselves for explanation by relevant biological mechanisms. In some respects RDoC is as much a philosophical revolution as a scientific one.

Accompanying this transition is the burgeoning body of first person accounts of patients, narrating the experience of mental disorder and psychiatric treatment, adding to the sources of knowledge in psychiatry.

Both these transitions in the psychiatric landscape create further impetus to revisit important topics pertaining to scientific research in psychopathology, not only among psychiatrists and psychologists, but also among philosophers and historians of science who specialize in thinking about the nature of scientific research and progress.

Possible topics include, but are not limited to:

What are the advantages and disadvantages of the RDoC framework for psychiatric research ?
How could recent philosophical work on mechanisms contribute to RDoC’s promise to develop a causal understanding of psychopathology?
Should latent variables be considered causes of behavior?
To what does construct validity refer in a psychiatric context?
Categories of mental disorder may not carve nature at the joints. Do competing dimensional models?
Can research in the history and theory of psychopathology contribute to the progress of scientific psychiatry? How can the work on values in feminist philosophy of science address the various tensions that exist between scientist versus practitioner perspectives?
What are the implications of the differences between folk psychological and scientific psychological concepts on scientific research on mental disorders?
Can patients’ experiences with mental illness contribute to scientific progress, or are they incommensurable?

Presentations will be strictly limited to 20 minutes, followed by 10 minutes for discussion.

Abstracts will be blind reviewed, so the author’s identifying information should be attached separately.

Abstracts should be 500-600 words and sent via email by November 15, 2015 to Şerife Tekin (stekin@daemen.edu) and Peter Zachar (pzachar@aum.edu). Notices of acceptance or rejection will be distributed in January.